What is the recommended treatment for male urinary tract infections (UTIs)?

Treatment of Male Urinary Tract Infections

All UTIs in males should be treated as complicated infections with a 14-day course of antibiotics when prostatitis cannot be excluded, though a 7-day course may be appropriate for hemodynamically stable patients who have been afebrile for at least 48 hours. 1, 2

Mandatory Pre-Treatment Steps

Always obtain urine culture and susceptibility testing before initiating therapy to guide appropriate antibiotic selection, as male UTIs have a broader microbial spectrum and higher antimicrobial resistance rates than uncomplicated UTIs. 1, 2 The common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 2

First-Line Empiric Antibiotic Options

For Patients Requiring Parenteral Therapy (Systemic Symptoms)

• Amoxicillin plus an aminoglycoside 1, 2
• Second-generation cephalosporin plus an aminoglycoside 1, 2
• Intravenous third-generation cephalosporin 1, 2

For Oral Therapy

Fluoroquinolones (ciprofloxacin or levofloxacin) may be used ONLY if ALL of the following criteria are met: 1, 2

• Local resistance rates are <10% 1, 2
• Patient has NOT used fluoroquinolones in the last 6 months 1, 2
• Patient does not require hospitalization 2
• Patient has anaphylaxis to β-lactam antimicrobials (alternative indication) 2

Trimethoprim-sulfamethoxazole is an alternative oral option if susceptibility is confirmed, though resistance rates have been increasing. 3

Treatment Duration Algorithm

14-Day Course (Standard Recommendation)

Use 14 days when prostatitis cannot be excluded, which applies to most male UTIs given the difficulty in definitively ruling out prostatic involvement. 1, 2 This duration is supported by a 2017 randomized trial showing 14-day ciprofloxacin achieved 98% cure rate versus 86% for 7-day treatment in men. 2

7-Day Course (Selected Cases Only)

Consider shortening to 7 days ONLY when BOTH criteria are met: 1

• Patient is hemodynamically stable 1
• Patient has been afebrile for at least 48 hours 1

Note the conflicting evidence: While one study suggests 7-day courses may be non-inferior 1, the most recent high-quality randomized trial demonstrates clear superiority of 14-day treatment in men (98% vs 86% cure rate). 2 Given this discrepancy, err on the side of 14-day treatment unless the patient clearly meets criteria for shorter duration.

Special Situations

Catheter-Associated UTIs

• Remove or change the catheter when possible before or during treatment 1

Structural Abnormalities

• Management of underlying urological abnormality is mandatory alongside antibiotic therapy 1, 2
• Consider imaging studies if recurrent infections occur to identify anatomical problems 1

Patients with Systemic Symptoms

• Initiate parenteral therapy until clinical improvement, then transition to oral therapy 1

Critical Pitfalls to Avoid

• Never start antibiotics without obtaining urine culture first - this is the most common error and prevents appropriate tailoring of therapy 1, 2
• Do not use fluoroquinolones empirically if local resistance exceeds 10% or if the patient used them in the past 6 months 1, 2
• Do not assume all male UTIs are simple cystitis - always consider prostatitis, which requires longer treatment duration 1, 2
• Do not ignore underlying anatomical or functional abnormalities that contribute to infection recurrence 1, 2
• Do not use fluoroquinolones in patients from urology departments where resistance rates are typically higher 2

Follow-Up Management

• Tailor antibiotic therapy based on culture results once available 1, 2
• Monitor for symptom resolution and consider follow-up urine culture in complicated cases 2
• Address any identified underlying abnormalities to prevent recurrence 2